A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

Document the infiltration.

Stop the infusion.

Elevate the arm.

Apply a warm compress.

Answer and Explanation

The Correct Answer is B

The correct answer is B.

Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action according to the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.

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Correct Answer is B

Explanation

B. “I should discuss this document with my family after I sign it.”It is important for clients to discuss their advance directives with their family members to ensure that their wishes are understood and respected. This helps prevent confusion and ensures that family members are aware of the client’s preferences for end-of-life care.

Incorrect Options:

A. “I am not allowed to change my mind once I sign this document.”Clients can change or revoke their advance directives at any time as long as they are competent to do so.

C. “My partner needs to be present when I sign this document.”While it is a good idea to have a witness, it is not necessary for the partner to be present. The requirements for witnesses vary by jurisdiction.

D. “An attorney will need to notarize this document for it to be valid.”Not all advance directives require notarization. The requirements vary by state or country, and some may only require witnesses.

A. Cover the wound with sterile, saline-soaked gauze. B. Raise the head of the bed to a 45° angle. C. Hold gentle, direct pressure on the protruding organ D. Place the client's knees in an extended position.

Correct Answer is A

Explanation

Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.

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A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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